RCC Treatments Flashcards
What is the R.E.N.A.L. Nephrometry Score?
a nomogram to assess the complexity of a renal tumor, and is predictive of surgical outcomes.
acronym for Radius, Exophytic, Nearness to collecting system, Anterior/posterior, and Location
What are the RENAL nephrometry scoring stratifications?
Low complexity: 4-6
Moderate complexity: 7-9
High complexity: 10-12 or has “h” suffix
RENAL Nephrometry Score: Radius points?
1: <4 cm
2: 4-7 cm
3: > 7cm
RENAL Nephrometry Score: Exophytic points?
1: >50% exophytic
2: < 50% exophytic
3: completely endophytic
RENAL Nephrometry Score: Nearness to collecting system points?
1: > 7mm
2: 4-7mm
3: < 4mm
RENAL Nephrometry Score: Anterior/posterior points?
No score given. Simply assign the tumor anterior, posterior, neither, or hilar
RENAL Nephrometry Score: Location points?
1: above/below polar lines
2: crosses polar lines
3:
a) > 50% of mass crosses polar line
b) or mass crosses axial renal midline
c) or mass completely between polar lines
*suffix “h” if mass is touching a main renal artery or vein (for herniation)
When is thermal ablation usually reserved for?
Masses < 4cm (T1a tumors)
Indications for partial nephrectomy:
Bilateral tumors
Tumors in solitary kidney
Small renal masses <4cm (T1a; lots of discrepancy here)
Decreased renal function or comorbidities that lead to poor renal function
What are some of the important key steps in a partial nephrectomy?
Early and complete vascular control
Diuresis (mannitol)
Ischemia time (<30 minutes of warm ischemia)
Adequate renal reconstruction to avoid urine leak and/or post-operative bleeding
When and why is mannitol used in partial nephrectomy?
Used prior to hilar clamping to reduce oxidative damage and free radicals and to induce diuresis
Treatment of stage 4 RCC with solitary metastasis?
Nephrectomy + metastasectomy
Treatment of stage 4 RCC and multiple mets?
Attempt cytoreductive nephrectomy and medical therapy
- if not medically cleared, surgically unresectable, or brain mets, then medical therapy only
When is regional lymph node dissection recommended?
If gross adenopathy seen, otherwise optional
Should adrenal gland be removed during radical nephrectomy?
Only if direct tumor extension (T4)
Post-surgery, recurrence is most likely within how long after surgery?
within 2 years
MC sites of recurrence?
Lung > bone > liver
Recommended AUA Guidelines for post-op CT scan and further follow up imaging for a pT1, N0, Nx tumor?
Post-op CT scan 3-12 months, then annual abdominal CT and CXR x 3 years
Recommended AUA Guidelines for post-op CT scan and further follow up imaging for a pT2-4, N-any tumor?
Post-op CT scan 3-6 months, semiannual abdominal CT and CXR x 3 years, then annual CT and CXR x 2 years
Recommended AUA Guidelines for post-op CT scan and further follow up imaging after renal ablation?
Post-op CT scan 3-6 months, then annual abdominal CT and CXR x 5 years
Recommended AUA Guidelines for post-biopsy or post-diagnosis CT scan and further follow up imaging for renal tumor Active Surveillance?
CT scan 6 months from diagnosis or biopspy, then annual CT and CXR indefinitely
What is hyperfiltration injury?
How much loss of functional renal tissue is generally concerning for this?
When reduction of one renal unit leads to increased perfusion, thus hyperfiltration of the remaining renal unit(s).
> 75% loss of functional renal tissue is concerning for hyperfiltration injury
What is the first indicator of hyperfiltration injury?
What specific nephropathy occurs with hyperfiltration injury?
Proteinuria is first indicator, which may then lead to hypertension.
Focal segemental sclerosis that progresses to renal failure
How is a urine leak after partial nephrectomy managed?
maintain or establish drainage (e.g. Jackson-Pratt drain, Double-J ureteral stent)
What are the targets of the three specific pathways, involved with the RCC tumorigenesis pathway of HIF-1, that are inhibited for the medical treatment of RCC?
- Tyrosine kinase inhibitors
- mTOR inhibitors
- VEGF inhibitors
What are the tyrosine kinase inhibitors for treating RCC?
Sunitinib (1st line therapy)
Sorafenib
Pazopanib
Axitinib
** TKI’s always end in -nib
Classic side effects of the tyrosine kinase inhibitors?
- Hand-foot syndrome (desquamation)
- Hepatotoxicity
- LV dysfunction, heart failure
- also diarrhea, fatigue
What is the mTOR inhibitor?
Drug schedule?
Temsirolimus
25mg IV weekly
What is the indicaiton/who gets temsirolimus?
indicated for poor risk patients with advanced RCC
What are the criteria that make a patient poor risk?
- LDH > 1.5x normal (bulky disease)
- Anemia
- Hypercalcemia
- Interval < 1 year from original diagnosis to the start of systemic therapy
- Karnofsky performance status < 70
- > 1 sites of metastasis
Classic SE of temisirolimus?
Mucositis, rashes, fatigue
What are the 2 cytokine therapies?
Interleukin-2
Interferon-alpha
Which cytokine therapy has 5% durable complete remissions, but has harsh side effects and is recommended in patients with excellent performance status (i.e. only pulmonary mets)
Interleukin-2
Interferon-alpha is always used in conjunction with what other drug?
Bevacizumab
What is the VEGF inhibitor?
Bevacizumab (Avastin)
What are the worrisome SE’s of bevacizumab?
hemorrhage
**wound healing complications
fatigue, proteinuria, HTN
How often is bevacizumb + IFN-a given?
10mg/kg IV infusion every 2 weeks until disease progression
What is the half-life of bevacizumab? Why must this be considered?
T 1/2 ~ 20 days
Drug MUST be stopped or helt at least 28 days (1 month) prior and after surgery.
- consider 80-100 days (3 months) to allow for 4-5 half-lives
- *must discontinue in patient with Fournier’s gangrene
Second line RCC medical therapies?
Everolimus (mTOR) Axitinib Sorafenib Pazopanib Temsirolimus (mTOR) Bevacizumab + IFNa IL-2
Drug schedule for Sunitinib?
50mg oral daily; 4 weeks on, 2 weeks off
May reduce dosing for side effects
